Keeping ahead of the bugs

Much has been spoke of and written about healthcare associated infections (HCAIs) over the past few years yet we still hear about and see problems in our hospitals regarding patients contracting these infections. In fairness the numbers are greatly reduced, but from the monthly statistics released by Public Health England (PHE), the former Health Protection Agency, there is great inconsistency between various hospitals, with some having achieved huge reductions whilst others have rates higher than acceptable.
Since 2005 when these types of infections were endemic in our healthcare facilities, and most medical professionals thought that there was little that could be done to reduce them, the government of the day made reducing them a priority through pressure applied by the media and campaigning from patient groups, including MRSA Action UK. Infection prevention and control became every hospital manager’s top priority and resources were allocated to bring about the reductions required by government.

Moving on from soft measures
Now that we have introduced what I call the ‘soft options’ of infection prevention and control, such as education of medical staff of the importance of hand hygiene, hospital cleaning, universal screening (now changed to targeted screening), and measures to address judicious antibiotic prescribing, the reductions in the reported HCAIs have reached a plateau and are in fact starting to rise.
From MRSA Action UK’s point of view, this is no coincidence. We stated in 2005 to the Department of Health that fighting these types of infections has to encompass the whole healthcare economy which includes social care, because fighting infections has to be an all or nothing affair – there can be no half-way house. All too often medical staff would use the excuse that patients were bringing these infections into the hospital, so in our opinion, it made common sense to prevent this in the first place. Sadly no-one listened to what we were saying. The consequence was that fewer resources were focused in tackling these infections in the community, creating a revolving door with hospital staff having to deal with the consequences as patients are admitted and, in many cases, readmitted.
In viewing the latest statistics from PHE it is clear to see that some 70 per cent of these infections are said to have been attributable to contraction in the community, yet not enough is being done to tackle this problem.
It is my belief that we may only ever lower these types of infections by 25 per cent. This would be welcomed but MRSA Action UK believe it would still be far too high for a modern healthcare system. I can confidently say this because in some Northern Scandinavian countries their infection rates with these types of bacteria are just one tenth of ours and we really need to look and ask why?
In truth these countries have been far more focused in tackling these bacteria from the start whilst we relied on antibiotics to cure infections contracted whilst in hospital. Unfortunately this was a false presumption that we could always keep ahead of the bugs. What we are now seeing are even more resistant bacteria evolving because we did not take the necessary precautions whilst we could. But it is still not too late to be able to match the best, and in my belief to actually be better if we so wished. What it will take is a complete rethink of the systems we have in our hospitals to take this challenge to the super bugs. It would require the political will and moral duty to ensure we are doing everything possible to ensure there are no gaps in the system, and the design of healthcare adapted to tackle the burgeoning threat of multi-drug resistant bacteria.

The next level
We can no longer solely rely on the education of medical staff on the importance of hand hygiene, hospital cleaning, targeted screening, and judicious antibiotic prescribing. We need to take this battle of infection prevention and control to a higher level using the tools of other industries.
To begin with there would have to be more openness and honesty within the medical profession. Hospitals will state that they are MRSA free, which is disingenuous of them as this only relates to MRSA bacteraemia. The NHS would be better off dealing with its problems through transparency and honesty, rather than through obfuscation and this deceit.

A re-think
One aspect that I consider needs to be viewed by the medical profession is a complete system rethink. This is the process of understanding how systems or processes influence one another within a complete entity, or larger system. In organisations such as the NHS, these systems consist of people, structures, processes and patients that work together to make an organisation ‘healthy’ or ‘unhealthy’. And a healthy NHS means a safer environment, for patients and staff. Using other types of processes such as ‘behavioural safety’, focuses on what people do and why they do it, then shifting to a method of working that is safer. This encourages a questioning attitude as to why certain work patterns are performed in a certain way. It looks for improvements not based on ‘it has always been done this way’, but looks for the best practice based on evidence. It must be all inclusive as it must focus on a ‘never-event-free’ performance.

Not repeating mistakes
One of the most important tools in safety driven industry is operational experience feedback (OEF). This is a process in which the effect of output or an input of a process or action is fed-back to members of staff in the primary organisation, say an NHS Trust, and then is relayed on to other organisations within the same context, to modify the next action, especially if there has been a never-event.
It has been proven that using tools such as these prevents the repeat of never-events and this could mean the repeat of the contraction of avoidable healthcare infections, as all too often the same mistakes are repeated. Using these tools can make the NHS safer, reduce costs and make it more efficient which is what we all want for the patients but more importantly it would make the NHS aim for ‘never-event free’ performance.
Antimicrobial resistance
A more pressing reason for wanting to consign avoidable healthcare infections to history is the burgeoning issue of antimicrobial resistance (AMR). Using antibiotics unnecessarily adds to the burden of resistance and accelerates the depletion of our present stock of antibiotics. It would make perfect sense to reduce infections in both our acute hospitals as well as within the community. We need improved diagnostics to target interventions and understand how and why the bacteria respond in the way they do. There needs to be an acceptance by both healthcare professionals and patients that we need to change attitudes and get smarter at tackling antimicrobial resistance.
Unless we learn to adapt to how to respond to infections in general, then healthcare will not be the same for future generations. Multidrug resistant (MDR) bacteria will become endemic, making the present situation pale in to insignificance – and we may cross what we call the ‘Rubicon’ from which there is no point of return.
At present we cannot rely on the pharmaceutical companies to deliver the new antibiotics we need; development can take 10 years before any class appear on the market for use. At present there are very few gram negative antibiotics in the pipeline and the new strains of gram negative bacteria are becoming increasingly resistant, and actually surpassing MRSA as the bacteria giving healthcare professionals cause for concern.
It will be our children and grandchildren that face an uncertain future in healthcare and this is why we need to take this battle of infection prevention to a new and higher level. Failure to do so will mean many more people dying unnecessarily in the not too distant future.

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